Preventing HIV with young people: the key to tackling the epidemic

Transcription

1 Preventing HIV with young people: the key to tackling the epidemic

2 This report seeks to describe the current situation of the HIV epidemic, the key challenges faced by adolescents and young people, and the actions that UNICEF is taking to respond in each region. Regional overview Eastern and Southern Africa In 2007, HIV prevalence in this region among young people age was 1.5 per cent for men and 4.5 per cent for women. Most of the epidemics in Southern Africa and parts of East Africa are generalised. In this region, girls are at greater risk of acquiring HIV due to a number of factors including multiple concurrent partnerships, intergenerational sex, transactional sex and gender-based violence. West and Central Africa In 2007, HIV prevalence in West and Central Africa among young people age was 0.7 per cent for men and 1.9 per cent for women. In this region, HIV transmission is associated with commercial sex work, although transmission also occurs in long-term heterosexual relationships, especially in Central Africa where some HIV infection rates exceed 5 per cent in the general population and the epidemic is increasingly similar to East and Southern Africa. Middle East and North Africa In 2007, HIV prevalence in Middle East and North Africa among young people age was 0.1 per cent for men and 0.2 per cent for women. In this region in 2007, there were 98,000 young people with HIV. With the exception of Sudan, the epidemics in this region are low prevalence and comparatively small. Various combinations of risk factors are associated with the epidemic; chief among them are unprotected paid sex and the use of contaminated needles for drug injecting. Latin America and the Caribbean In 2007, HIV prevalence in Latin America and the Caribbean among young people age was 0.5 per cent for men, and 0.4 per cent for women. In this region, HIV prevalence has stabilised in several countries at less than 1 per cent. Transmission occurs primarily among men who have sex with men, sex workers and (to a lesser extent) injecting drug users. The Caribbean has the world s second-highest regional prevalence of HIV (after sub-saharan Africa) and the main mode of transmission is unprotected heterosexual sex, with commercial sex and sexual exploitation playing a significant role in many countries. South Asia In 2007, HIV prevalence in this region among young people age was 0.3 per cent for men and 0.2 per cent for women. All of the countries in this region have a low HIV prevalence with no country exceeding 0.5 per cent. However, low national averages mask serious epidemics concentrated in some geographical areas and among groups engaging in particular high risk behaviours. Unprotected sex in the context of sex work, unsafe injecting drug use, and unprotected sex between men account for an estimated 75 per cent of all infections in the region East Asia and Pacific In 2007, HIV prevalence in East Asia and Pacific among young people age was 0.2 per cent for men and 0.1 per cent for women. Most countries in this region have low prevalence or concentrated epidemics. Key drivers of the epidemic in East Asia and Pacific are the use of non-sterile injecting equipment, unprotected transactional sex and, to a lesser extent, unprotected sex between men. Central and Eastern Europe (CEE) and the Commonwealth of Independent States (CIS) In 2007, HIV prevalence in this region among young people age was 0.8 per cent for men, and 0.5 per cent for women. This region is experiencing one of the steepest increases in the spread of HIV worldwide. Each of the HIV epidemics in this region is concentrated largely among injecting drug users, sex workers, and their various sexual partners.

3 CONTENTS Foreword 2 Introduction 3 Global response to the HIV epidemic 4 HIV prevention with young people 6 Eastern and Southern Africa 8 West and Central Africa 12 Middle East and North Africa 14 Latin America and the Caribbean 16 South Asia 18 East Asia and Pacific 20 Central and Eastern Europe and the Commonwealth of Independent States 22 United Kingdom 24 Conclusion 25 Recommendations 26 References 27 Glossary 28 1

4 FOREWORD by Jimmy Kolker and Michel Sidibé Jimmy Kolker Michel Sidibé In 2005 UNICEF, UNAIDS and partners launched the Unite for Children, Unite against AIDS campaign, calling for children and young people to be at the heart of the global response to HIV and AIDS. Since this launch we have made progress, with the number of mothers receiving treatment to prevent them from passing HIV to their babies and the number of children accessing treatment more than doubling. However the vast majority of women and children who need treatment still do not have access to it and young people continue to remain at the centre of the HIV epidemic, accounting for almost half of all new HIV infections worldwide. Young people have grown up in a world transformed by HIV and AIDS, but the majority of them still lack comprehensive and correct knowledge about how to prevent HIV infection, or do not have the power to act on that knowledge. In sub-saharan Africa, home to the highest rates of HIV infections, girls and women are particularly vulnerable. Young people are diverse, and HIV prevention approaches have to adapt to the realities of their lives, recognising the cultural and social factors that increase their vulnerability to HIV. UNICEF and UNAIDS work in partnership with governments, UN agencies and NGOs to identify young people who are at risk and develop ways to reach them. The world has agreed that young people have the right to education, information and services that could protect them from harm. The full realisation of these rights is essential to mobilise and empower young people in order to prevent the spread of HIV. Parents, teachers, community and political leaders and other adults need to speak frankly and openly to young people about sex and relationships, to protect them from abuse and exploitation, and to build a culture of empowerment where young girls in particular can make their own choices free from coercion. We have to work with young people to design and deliver prevention programmes that address the realities of their lives. We must not let our own fear threaten our children s futures. Only a combination of measures, educational, practical, social and cultural, based on open communication, youth participation and wise leadership can bring the progress we need if the next generation is to live free from HIV. Jimmy Kolker is Associate Director, HIV and AIDS Section, UNICEF Michel Sidibé is Executive Director, UNAIDS A comprehensive, rights-based and evidence-informed prevention response, linked with access to effective youth-friendly health services, should be at the core of national and global programmes. Prevention is for life, and this response must be sustained as young people continue into adulthood. 2

5 INTRODUCTION Three decades into the HIV epidemic, children and young people remain at the heart of the disease s effects, yet all too often at the periphery of the world s response. Almost every minute of every day, another two young people are infected with HIV. 1 Young women remain particularly vulnerable to HIV; of the 5.5 million young people age with HIV, about two thirds are female. 2 To date, campaigns on HIV and AIDS have focused successfully on areas such as the prevention of mother-to-child transmission (PMTCT) and increasing the availability of affordable anti-retroviral medicines for adults and children. Although there is still much more to be done in these areas, in order to begin to halt and reverse the epidemic, we must also prevent new infections among young people. The focus on other priorities and the difficulties of speaking about and changing sexual behaviour among young people have combined to ensure that comprehensive prevention strategies have been given far too little attention. It is time to change that, and this is the purpose of this report. Social, political, cultural, biological and economic factors make young people particularly vulnerable to HIV, and they continue to be disproportionately affected in the epidemic. Even though young people are more likely than adults to adopt and maintain safe behaviours, insufficient attention is being directed towards preventing future transmission of the virus among them. Just seven countries have met the global target to reduce prevalence among young people by at least 25 per cent by Young people offer the best hope of halting the spread of HIV, yet globally the vast majority remain inadequately informed about sex and sexually transmitted infections (STIs). Many young people have heard of AIDS, but do not know how HIV is spread and do not believe they are at risk. Even those young people who know how HIV is transmitted often lack the ability to assess their risk of infection and are unable to protect themselves because they lack the skills, the support, or the means to adopt safe behaviours. Yet there are some promising trends. When young people are equipped with correct information and skills, have access to prevention services, and are provided with an enabling and protective environment, HIV infection can be averted. Evidence suggests that HIV prevalence among young people is declining in many countries, in some of them significantly. Since , HIV prevalence among young women age attending antenatal clinics has declined in 14 of the 17 countries with adequate survey data. 6 Furthermore, in a number of countries, such as Burkina Faso and Zimbabwe, changes in sexual behaviour have been followed by a decline in the number of new HIV infections. Many countries have reported increasing condom use among young people with multiple partners and there are encouraging signs that young people are waiting longer to have sexual intercourse in high prevalence countries such as Burkina Faso, Cameroon, Ethiopia, Ghana, Malawi, Uganda and Zambia. 7 This report seeks to describe the current situation of the epidemic, the key challenges faced by adolescents and young people, and the actions that UNICEF is taking to respond in each region. Florence Kangai, age 11, leads other children in a protest song about HIV at a community support group in Isiolo, eastern Kenya. UNICEF supports the group with nutrition supplements, equipment and training. UNICEF Kenya/Sara Cameron Sub-Saharan Africa is home to the largest number of young people with HIV almost two-thirds of the global total. South Asia follows with nearly 700,000 young people with HIV. 4 In Central and Eastern Europe, the Russian Federation and Ukraine have the fastest growing epidemics in the world, and young people account for a large proportion of the number of people with HIV. 5 Of the millions of young people with HIV, many face damaging stigma and discrimination and lack good-quality counselling and services to help them live with a chronic disease and successfully make the transition to adulthood. 3

6 GLOBAL RESPONSE TO The scale of the HIV epidemic remains daunting and young people remain disproportionately affected, accounting for 45 per cent of new adult infections in The dimensions of the HIV epidemic remain staggering. In 2007 alone, there were an estimated 33 million people with HIV (of whom 2 million were children under the age of 15), 2.7 million people were newly infected, and 2 million died from AIDS. 1 Though these statistics make for grim reading, for the first time since AIDS was recognised 27 years ago, there are signs of major progress in tackling the epidemic. The annual number of AIDS deaths has declined in the past two years, partly as a result of the substantial increase in access to HIV treatment. By the end of 2007, nearly 1 million more people in low- and middle-income countries were receiving anti-retroviral medicine than in 2006, bringing the total number of people receiving treatment to almost 3 million. 2 This represents more than a seven-fold increase in four years. People with HIV are living longer and have a better quality of life. There have also been encouraging trends in providing health services for women and children. The proportion of pregnant women with HIV receiving treatment to prevent mother-to-child transmission increased from 10 per cent in 2004 to 33 per cent in The number of children under the age of 15 in low- and middle-income countries receiving treatment more than doubled between 2005 and 2007 (from 75,000 to almost 200,000). However, this means that about 10 per cent of the total number of children with HIV are receiving antiretroviral treatment. 4 Although increased political commitment and allocation of resources are having an effect, there remain great and enduring challenges. Despite the successes in expanding treatment, the number of new HIV infections continues to outpace the delivery of treatment. Currently for every two people put on anti-retroviral medicine, another five are newly infected. 5 Unless we take urgent steps to intensify HIV prevention we will fail to capitalise on the successes of the past few years. Indeed, unless we sharply reduce the number of new infections, it will become increasingly difficult to realise the goal of universal access to HIV prevention, treatment, care and support by According to UNAIDS, the failure to make essential HIV prevention services widely available for the mostin-need populations is a key reason for the limited impact of prevention efforts worldwide. While 87 per cent of countries with targets for universal access have established goals for HIV treatment, only around half of these countries have targets for key HIV prevention strategies. 6 An analysis of national HIV plans showed that International commitments related to HIV and AIDS and young people Millennium Development Goals In September 2000, the UN member states made a commitment to achieve the Millennium Development Goals (MDGs), including MDG 6, which is to combat HIV/AIDS, malaria and other diseases. United Nations General Assembly Special Sessions on HIV and AIDS In the 2001 UNGASS Declaration, UN member states committed to reducing HIV prevalence by 25 per cent among young men and women age in the most affected countries; ensuring that by 2010 at least 90 per cent of young men and women age have access to information and services to reduce their vulnerability to HIV infection. Universal access In 2005, the G8 countries at the Gleneagles Summit and the UN General Assembly World Summit called for the development and implementation of a package for HIV prevention, treatment and care, with the aim of coming as close as possible to universal access to treatment for all who need it by Unite for Children, Unite against AIDS In 2005, UNICEF and UNAIDS launched the Unite for Children, Unite against AIDS campaign to provide a framework for addressing the specific impact of HIV and AIDS on children and young people. This global campaign focuses on four areas: preventing HIV infection among adolescents and young people; PMTCT; providing paediatric treatment; and protecting and supporting children affected by HIV and AIDS. UN High Level Meeting on AIDS The Political Declaration from the High Level Meeting in 2006 stated the need to ensure an HIVfree future generation through the implementation of comprehensive, evidence-based prevention strategies for young people. Member states made a commitment to set national targets for prevention, treatment and care for

7 O THE HIV EPIDEMIC prevention responses are not always prioritised and often these plans do not focus on reducing the highest risk behaviours.7 Furthermore, 69 per cent of countries with low-level or concentrated epidemics report having laws, regulations, or policies that pose barriers to the use of HIV services by populations most at risk of HIV infection.8 Although there have been significant increases in financing for HIV during this decade, if current funding trends continue then the gap between resources available and the amounts needed to achieve the agreed target of universal access to prevention, treatment, care and support by 2010 will widen over the next several years. Available funding for HIV will National responses have also, in most have to more than quadruple by 2010 We need to make the same cases, failed to address the underlying gains in HIV prevention that we compared to 2007 up to US$ 42.2 social drivers of HIV. Prevention billion and continue to rise to US$ 54 are making in HIV treatment. interventions have tended to focus on billion by We have a critical window of changing the behaviour of individuals without addressing the political, Despite all the attention given to opportunity over the next 10 economic and social determinants of HIV over the last decade, and the years to dramatically slow the risk. Non-governmental informants in undoubted gains in access to treatment rate of new infections, and 28 per cent of countries state that they and preventing mother-to-child have laws, policies, or regulations that ultimately reverse the epidemic. transmission, the number of people actually impede young people s access with HIV continues to grow and AIDS Helene Gayle MD MPH, to HIV prevention and other services.9 remains the leading cause of death in President and CEO of CARE USA Tackling these issues is a long-term Africa. Young people, especially girls in effort and requires political commitment at the highest sub-saharan Africa, bear the brunt of this failure. Unless level. However, if ignored, they will continue to undermine and until political will, leadership and resources are made all other prevention interventions. available for prevention services, we will not begin to halt and reverse the HIV epidemic. As we get closer to the As history has shown, governments often favour Millennium Development Goal target date of 2015, now spending on activities that will produce visible returns in is the time to redouble our efforts. the short term, such as treatment. Prevention efforts, however, may take longer to produce results. The global financial crisis poses a new challenge with developing countries potentially facing funding cutbacks as donor governments reconsider their levels of development assistance. If funding is cut, it may prove difficult to sustain and expand the successful prevention programmes that are needed to tackle the spread of the epidemic. A global view of HIV infection, 2007 global FAI G U R E view 2. 2 of HIV infection, million people [30 36 million] living with HIV, 2007 Adult prevalence (%) 15.0% 28.0% 5.0% <15.0% 1.0% <5.0% 0.5% <1.0% 0.1% <0.5% <0.1% No data available In 2007, there were 33 million people with HIV. Source: UNAIDS, 2008 Report on the Global AIDS Epidemic, UNAIDS, Geneva, 2008, p final7.indd 5 5/5/09 17:41:19

8 HIV PREVENTION WITH The probability that adolescents and young people will acquire HIV depends on a number of different factors, including whether they engage in HIV risk behaviours such as unprotected sex with a partner who has HIV, or using non-sterile injecting equipment. Forced or violent sex without a condom with a person who is HIV positive also increases the probability of HIV transmission, as does the frequency of unprotected sex, the number of partners, the age of their partners, especially concurrent partners, and any co-infection with a STI. It is important to recognise that some adolescents engage in multiple risk behaviours. Adolescents injecting drugs, for example, may sell or buy sex in exchange for drugs. This interplay between injecting drug use and unprotected sex, much of which is transactional, increases the risk of acquiring HIV. Yet prevention strategies often focus on just one risk group or behaviour, and rarely address multiple risk-taking behaviour. The presence of factors that reduce the ability of individuals to avoid HIV infection (such as poor knowledge of HIV risk, lack of access to health services, social/cultural norms and practices that stigmatise and disempower certain populations) and the absence of protective factors (such as schooling, a supportive family, an enabling environment) 1 increase young people s vulnerability and likelihood of engaging in behaviour that increases their risk of HIV infection. 2 Young people vulnerable to HIV include: young people lacking parental care; those who have dropped out of school; those who are mobile or displaced; socially excluded young people and those who live in areas of high HIV prevalence (especially young women). 3 Young people most at risk of infection include: injecting drug users who use non-sterile injecting equipment; men who have unprotected sex with other men; those who are involved in sex work, including those who are trafficked for the purpose of sexual exploitation and have unprotected (often exploitative) transactional sex, and men who have unprotected sex with sex workers. 4 It s important that national prevention responses ensure that programmes combine risk reduction with mitigation of vulnerability. 5 Know your epidemic, know your young people Governments need to know their epidemic in order to deliver effective prevention programmes. This means understanding the dynamics and the nature of the different epidemics occurring within their country. Without knowing where the most recent infections are occurring and which risk behaviours are driving the epidemic, prevention responses are easily misguided. Consensus in the scientific community and in civil society is that interventions based on such understanding and tailored to the local situation are needed and, more importantly, can work. At the national level, UNICEF is supporting modes of transmission studies being carried out by UNAIDS and the World Bank in Eastern and Southern Africa and in Latin America, which aim to help countries analyse how the most recent HIV infections were transmitted and understand why they occurred. 6 UNICEF is also supporting situational analysis to better understand which young people are most at risk of HIV and why. Data collection on risk behaviours among young people has been supported by UNICEF in seven countries in Eastern Europe. Risk mapping at community level has been carried out in a number of countries, such as in Cameroon, to determine when and where adolescents and young people are at risk, to assist local efforts to implement and tailor the right intervention strategies. Empowered with this information, countries can develop an effective combination prevention response by matching their funding to prevention programmes that focus on where the new infections are occurring or are likely to arise. This must include the right mix of structural, biomedical and behavioural prevention actions to suit the HIV epidemic and the needs of those who are most at risk, in the same way that the right combination and dosages of medicines for anti-retroviral treatment are chosen. Structural strategies aim to change the context that contributes to vulnerability and risk; biomedical interventions block infection or decrease infectiousness, and behavioural strategies attempt to motivate behavioural change within individuals and societies. Realising the rights of young people Young people are more likely to reduce risky behaviours when their rights to access relevant information, skills, and services in a safe and supportive environment are fully respected. UNICEF supports mass-media interventions, life skills-based programmes in schools and communities, peer education, condom promotion, youthfriendly health services, harm reduction, counselling and testing; all of which have demonstrated effectiveness in reducing risk and vulnerability to HIV infection. 7 The right to information Currently just 30 per cent of young men and 19 per cent of young women age in developing countries have correct knowledge about HIV and how to avoid transmission. 8 Young people cannot protect themselves unless they have the facts about HIV and AIDS. They need clear information about how HIV can be transmitted, which behaviours may put them at greater risk of acquiring HIV, and the dispelling of common misconceptions about HIV and AIDS. Young people also need to know how and where to access sexual and reproductive health (SRH) services, and harm reduction services for those who inject drugs or who may be at risk of injecting drugs. Young people need this information before they become sexually active or engage in risky behaviours, and the information needs to be regularly reinforced, updated and developed. 6

9 YOUNG PEOPLE Many countries that include HIV education in schools prioritise messages focused on abstinence, which often discourages forthright discussions about condoms and safer sex. It is important that teachers are given appropriate and ongoing training on how to deliver clear, honest and effective HIV prevention education. Information alone is not enough to change behaviour. 9 Young people need skills to put what they ve learnt into practice. Teaching adolescents and young people risk-reduction skills to make informed decisions about sex and drug use, solve related problems, think critically, cope with emotions and stress, and negotiate can empower them with the ability to manage challenging situations, to adopt healthy behaviours, and the capacity to act on their own decisions. UNICEF works with the UN, non-governmental organisations (NGOs) and national governments to provide life skills-based education, which includes HIV prevention, in the classroom. Life skills-based education is an important approach to enable discussions about sexuality, relationships and substance abuse. There is important evidence that school-based sex education can be effective in changing the knowledge that leads to risky behaviour. However, to have greater impact, programmes need to be in line with evidence-informed characteristics of effective prevention efforts. To date, it has been difficult to implement such programmes and expand them appropriately. It is also crucial that national responses include efforts to reach the many adolescents and young people who are not at school. The right to access health services Young people s sexual and reproductive health needs are different to those of adults, and remain poorly understood and inadequately served in many parts of the world. Young people are less likely than adults to know where to access HIV services and commodities, such as condoms, and less likely than adults to seek treatment for STIs (which increase their vulnerability to HIV). Services for young people should be free or affordable. They should include: sexual and reproductive health information and counselling, including HIV prevention services; HIV counselling and testing (including referral to HIV prevention services, irrespective of the outcome of testing); condoms; diagnosis and treatment of STIs; male circumcision; and referral to treatment, psychosocial support and care services for young people with HIV and for those affected by it. In addition, young people injecting drugs need harm-reduction services, and pregnant young women need referral to PMTCT services. 10 It s important that health workers are given training on how to provide confidential, non-judgemental and ageappropriate services for young people. Health facilities should also be in a location and open at hours that are accessible to young people. The right to grow up in a safe and supportive environment In order to access and use information, skills and services, young people need to be free from abuse, conflict and exploitation. Factors such as social and cultural norms and laws that stigmatise and disempower certain groups can act as strong barriers to effective HIV prevention. Political leadership is vital to the development and maintenance of a safe and supportive environment. Young people with HIV face particular challenges around accepting their HIV status and disclosing it to those close to them, as well as adhering to treatment regimes and coping with feelings of isolation and stress. 11 Many young people lack proper access to health and social support services, and face considerable stigma and discrimination. Young people with HIV need information about how to live a positive and healthy lifestyle, how they can influence the progression of the disease, what their treatment and care options are, and how to prevent transmission to others. Health systems must also be supported by strong social welfare systems. In Latin America and the Caribbean, UNICEF is strengthening links between HIV services, early childhood development and welfare systems. In Haiti, more than 2,600 new mothers with HIV were given parenting skills training in Cité Soleil, Port-au-Prince, and hundreds of children with HIV benefited from community support programmes. UNICEF-led training resulted in 150 public health, education, and social service workers equipped with knowledge and skills in nutritional management, adherence and psychosocial counselling to deliver quality services to children, young people and families affected by HIV and AIDS. The right to express views and have them taken into account Young people should be meaningfully involved in the planning, design, implementation, monitoring and evaluation of interventions that affect them. UNICEF is committed to youth participation and encourages young people to participate in the preparation, implementation, monitoring and evaluation of local, national, regional and global policies, plans and programmes. Along with UNAIDS, the United Nations Population Fund (UNFPA) and the World Health Organization (WHO), UNICEF has supported the inclusion of specific HIV prevention strategies aimed at young people into the national plans of a number of countries in Eastern and Southern Africa (including Botswana, Lesotho, Namibia and Swaziland) and encouraged young people s participation in the development of such plans. Malawi has completed a national acceleration plan for prevention among young people. In Namibia, a prevention sub-committee prioritising young people has been established under the national coordination structure, and the HIV prevention response includes a focus on mostat-risk adolescents. 7

10 EASTERN AND SOUTHER Southern Africa, which is experiencing an epidemic unmatched by any other region in the world, remains at the heart of the global HIV epidemic. Eastern and Southern Africa s epidemics vary significantly from country to country. There are also great national variations between regions and between rural and urban areas. In sub-saharan Africa, for instance, urban areas consistently show higher rates of HIV prevalence than rural areas. Southern Africa, which is experiencing an epidemic unmatched by any other region in the world, remains at the heart of the global HIV epidemic. In the Southern African countries where HIV prevalence is extremely high, the probability that one s partner has HIV is about 1 in 5. This results in much higher levels of exposure to HIV than anywhere else in the world. 1 Here, adolescent girls and young women remain disproportionately vulnerable to HIV infection, particularly in the seven hyper-endemic countries (Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia and Zimbabwe), where prevalence is greater than 15 per cent. 2 In Southern Africa, adolescent girls are 2 to 4.5 times more likely to get HIV than males of the same age. 3 Due to the toll of the epidemic, average life expectancy at birth in Southern Africa has fallen dramatically to below 50 years. By 2010, life expectancy could be as low as 40 years in Swaziland and 43 years in Zambia. 4 In some Southern African countries (such as Zimbabwe) changes in sexual behaviour have resulted in a reduction in new HIV infections, but the total number of new infections remains high. 5 In other countries, such as Mozambique, the epidemic continues to grow with infections among young people also increasing. 6 In the countries of East Africa, HIV prevalence has either decreased or remained stable in the last few years. As a result, average life expectancy at birth in East Africa is expected to increase. 7 As in Southern Africa, women in East Africa face considerably higher risk of HIV infection than men, especially at younger ages. The urban areas of Eastern and Southern Africa bear a disproportionate weight of the HIV epidemic, with a quarter of the total epidemic in the region concentrated in the 12 major metropolitan areas (Johannesburg, Cape Town, Durban, Nairobi, Addis Ababa, Dar Es Salaam, Luanda, Pretoria, Harare, Kampala, Maputo, Antananarivo, Lusaka, and Port Elizabeth). Several of these metropolitan epidemics are larger than most of the national epidemics in Africa and certainly than epidemics in the rest of the world. However, most national HIV responses to date have not included an explicit focus on cities. 8 Why are HIV infection rates so high in Southern Africa? Southern Africa is experiencing a devastating combination of HIV-related risks. Factors that increase vulnerability and risk such as multiple and age-disparate partnerships, gender-based sexual violence and low rates of male circumcision all coexist and coalesce in these societies. There are a number of key factors contributing to the high rates of HIV infection in Southern Africa. Poor understanding of risk Less than half of all young people in most countries in Southern Africa have comprehensive knowledge of HIV. This means that more than 50 per cent of young people cannot name two ways of transmitting HIV and three common misconceptions about methods of transmission. 9 Moreover, even those young people who have this knowledge do not necessarily have an accurate picture of the risks associated with different practices and behaviours. Recent data shows that the majority of new HIV infections among young women take place within marriage and long-term regular relationships, which are often perceived as low risk. 10 Condom use is occasional and inconsistent, and sexual intercourse much more frequent in these types of relationships. In addition, in many of these relationships one or both partners also have another sexual partner a so-called concurrent sexual relationship, which provides a much wider sexual network for exposure to the virus. However, communities and individuals have very little understanding of how HIV is transmitted through sexual networks and the risk from concurrent relationships. 11 There is also little awareness of the link between an individual s viral load and their infectiousness. HIV discordance, when one member of a couple has HIV, is not well understood, even among people who have tested positive and have received counselling services. 12 There is very poor understanding among adolescent girls that having sex with older men increases the risk of HIV infection 13, even though current evidence indicates that large numbers of young women actively engage in concurrent relationships with older men. Intergenerational sex and transactional sex often occur in the contexts of unequal power relations that inhibit women and girls ability to make choices about safer 8

11 N AFRICA sexual practices. Gender based violence (GBV) is common in Southern Africa. Sexual violence can lead to HIV infection directly, as trauma increase the risk of transmission. GBV also increases HIV risk indirectly. There is evidence of higher HIV risks among people with a history of gender-based violence and higher rates of GBV among those who have HIV. 14 Reports in 2002 from Southern Africa showed that 18 per cent of women age personally experienced violence in the previous 12 months. Further, some 40 per cent of women across the region said that they would have sex if their partner refused to use a condom and a similar proportion did not think that women had a right to refuse sex with their partner. 15 One in every five youths age said they had been forced or coerced to have sex, and one in 10 said they had forced sex on someone else. Overall, open communication on issues of sex and sexuality is limited, and sexual and reproductive health (SRH) knowledge is quite low even among teachers and other adults. 16 Young people have relatively little access to youth-friendly health services and most HIV prevention services are not sensitive to their needs. Young people clearly need more comprehensive knowledge of the risks that they are exposed to in order to understand the levels of risk and be motivated to consider behaviour change. Poor targeting of prevention programmes In many Southern African countries, women in their early to mid-20s have significantly higher HIV prevalence There is a clear need for HIV-prevention activities to focus on women age than females age In Lesotho and Swaziland, for example, HIV prevalence among girls age is around 6 per cent, but rises to nearly 30 per cent in Lesotho and over 40 per cent in Swaziland among women age This data strongly suggests that there is a clear need for HIV-prevention activities to focus on women age 15 17, where prevalence rates are still relatively low. This age group is just starting to become sexually active and is most in need of SRH and HIV information and skills. However, much of the HIV programming with and for adolescents in the region does not effectively apply an age- and sex-disaggregated approach. Although adolescent girls are often defined as the priority group among young people within national HIV prevention strategies and plans, it is often difficult to find specific programming designed with and for girls. Prevention programming urgently requires a differentiated response when working with and for young people. Assumptions cannot be made about which groups of young people are most at risk of HIV infection. Decisions must be made on available evidence. For example, recent data clearly shows a strong correlation between wealth and HIV prevalence. In many countries, there are higher rates of HIV among the wealthiest young women, not the poorest. In fact, many of the young women with HIV come from households HIV and young women in Eastern and Southern Africa Eritrea Djibouti Somalia HIV prevalence among young women age Ethiopia Rwanda less than 1% Uganda Kenya Seychelles 1% to 4% Angola Tanzania Burundi Comoros 5% to 10% Zambia Mozambique 10% to 15% Zimbabwe Namibia Botswana Madagascar Malawi 15% to 20% 20% to 25% South Africa Swaziland Lesotho Source: UNICEF, UNAIDS, WHO and UNFPA, Appendix: Country Fact Sheets, Children and AIDS: Third Stocktaking Report, UNICEF, New York,

12 EASTERN AND SOUTHER with better incomes, and live in urban settings with increased access to communication and services. 18 There is growing evidence that being in school reduces the risk of HIV infection among girls, therefore efforts to keep girls in school until secondary-school graduation must be intensified. 19,20 However, it is vital that prevention responses are tailored to specific contexts. Data from some countries, such as Malawi, show that HIV prevalence in young women age is highest among those with most education. 21 Low rates of male circumcision Uncircumcised men have a much higher probability than circumcised men of getting HIV if they have unprotected sexual intercourse with an HIV-positive woman. Studies have shown that male circumcision provides a 50 to 60 per cent reduction in the risk of HIV infection. 22 In Southern Africa, condom use is inconsistent and male circumcision levels are very low. This combination, in a context where HIV prevalence is above 15 per cent among adults, substantially increases the probability of HIV transmission to uncircumcised males who have multiple and concurrent sexual partners. Priorities for action HIV prevention in hyper-endemic countries must be elevated to the status of a national emergency. It must be an integral part of a country s development plan; multiple sectors in government and civil society must be HIV prevention in hyperendemic countries must be elevated to the status of a national emergency. actively engaged; and the response must be led at the highest level of the state, as is the case in Botswana. 23 UNICEF and key partners have been advocating for a renewed and clear focus on adolescent girls as a mostat-risk population in HIV-prevention programming in Southern Africa. Together with our partners, UNICEF is calling for action to: Increase knowledge around behaviour and risk Civil society organisations need to be supported to include an explicit focus on young people, in particular focusing on increasing risk perceptions of serial and concurrent relationships among young women, risks from age-disparate sex and risks within marriage and long-term partnerships. Young people need more knowledge about the level of protection provided by male circumcision, as well as the science around transmission risk in the acute and latent phases of HIV infection. Increase focus on adolescent girls and their partners UNICEF is working in partnership with government and civil society to ensure that adolescent girls are clearly defined as a most-at-risk group in national HIV plans and strategies. A results-based focus on adolescent girls is now being prioritised in the national prevention strategies, behaviour-change communication strategies, or national plans of Malawi, Zambia, Lesotho, Swaziland, Namibia and Botswana. Programmes to increase the prevalence of male circumcision and address social norms around male sexual risk-taking behaviours should support this. August, age 11, participates in a Window of Hope life-skills programme at her school in Namibia. She says, We learned about HIV and AIDS, that it is a killing disease and I must protect myself. We also learned how to care for people with AIDS. UNICEF Namibia/Figueira 10

13 N AFRICA Address social norms There must be increased community mobilisation, with the strong involvement of men, to address the factors that increase young women s risk of infection or potentially limit their ability to act. Faced with the high levels of gender-based violence, women need sexual assertiveness skills and the capacity to put risk reduction knowledge and behaviours into practice. HIV prevention policy should recognise the direct and indirect implications of GBV for HIV prevention and ensure that the reduction of GBV forms part of HIV prevention programmes. Effective interventions are likely to include a structural component and a GBV awareness component. Communities need to challenge the risky behaviours of young women and younger and older men. Parents and community leaders also need to be challenged around accepting attitudes and behaviours that put young women in situations of risk from early marriage to intergenerational sex. Strengthen links between prevention and treatment National programmes have made progress in expanding treatment services, especially HIV testing and counselling. We must expand and promote the link between prevention and treatment. We must ensure that young people receive appropriate prevention counselling within existing voluntary testing and prevention of mother-to-child transmission services. Interventions, like a Test for the Test, have the potential to reach great numbers of young people at risk. In 2006, for instance, young people age accounted for over 40 per cent of the 1 million tests during the national HIV Testing Week in Malawi. 24 Increase youth-friendly services It is also important to ensure that young people with HIV have access to HIV services, as currently most services are designed for adults. 25 As HIV testing, counselling and referral systems are expanded, young people must be meaningfully involved in the design and operation of these services. For example, in 2008, UNICEF Zimbabwe successfully advocated for the representation of adolescents with HIV in the national Adolescent Sexual and Reproductive Health Forum. More research on the structural drivers of the epidemic Evidence suggests that the risks for girls and women in Southern Africa are likely to rise in the immediate future. Recent studies in Botswana, Swaziland, Malawi, Zambia and Tanzania have shown associations between acute food insecurity and unprotected transactional sex among poor women. 26 More knowledge is needed on the structural drivers of the epidemic including the relationship between alcohol and HIV risk, wealth and HIV risk 27, as well as HIV prevention efforts targeting discordant couples. Mulu Melka s right to be educated Mulu Melka, age 13, lives with her parents in Oromia, southern Ethiopia. When she was 11, she was abducted by a man. She escaped, but fearing that she might have to marry her captor as is often the case in traditional communities she sought refuge with an aunt who persuaded her parents to take her back and send her to school. I didn t want to marry that man, Mulu says. I wanted to continue my studies. Seven other girls who attend Mulu s school have been abducted this year. The following year, Mulu s parents forced her to marry an older man she had never met. But, before the marriage was consummated, Mulu insisted that both she and her new husband be tested for HIV. At school, Mulu had learned about HIV and how it is transmitted. The tests showed that Mulu was HIV negative but that her husband had HIV and, on that basis, the community elders immediately annulled the marriage. Mulu was determined to finish school but her parents were concerned about the shame the incident could bring on their family and the continued community pressure for their eldest daughter to marry. Pressure for girls to marry is also related to poverty, because of the bride price paid to a girl s family on her wedding day. And, given high rates of abductions and sexual violence, parents also hope to protect their daughters by marrying them at an early age. Mulu s parents discussed their concerns with Abebech Simel, the district official responsible for promoting girls education, and Mulu Melka, age 13, is determined to finish school. UNICEF Education Officer Kefyalew Ayano. Eventually, her father agreed to support Mulu s wishes. Through her ingenuity and courage, Mulu protected herself from HIV and saved herself from losing out on an education. Her experience has only strengthened her conviction that going to school is crucial, especially for girls. Girls need to be educated so they can be self-reliant and know how to protect themselves, says Mulu. She plans to be a teacher. UNICEF/HQ /Andrew Heavens 11

14 WEST AND CENTRAL AFR Young people in West and Central Africa are growing up with political instability and conflict. They are among the world s poorest young people, have high youth unemployment rates and extremely low rates of school attendance. Airound one in six of all HIV infections worldwide occurs in West and Central Africa. 1 HIV prevalence among people age varies widely between countries from 0.5 per cent to 6.2 per cent and significantly within countries too. 2 Most of the comparatively smaller HIV epidemics in West Africa are stable or are declining. The large population of Nigeria means that it has the world s second largest number of people with HIV (after South Africa). However, according to HIV infection trends among women attending antenatal clinics, infection rates here appear to have stabilised at around 3 per cent. 3 Sex work is an important factor in many of West Africa s HIV epidemics. In Mali, more than one third of female sex workers surveyed in 2006 had HIV, and infection levels exceeding 20 per cent have been documented among sex workers in Senegal and Burkina Faso. The importance of men having sex with men in the epidemics of West Africa is being increasingly recognised. Estimates from Senegal suggest that up to 20 per cent of new infections in Senegal may be attributable to sex between men. High proportions of these men are also married and/or have sex with other women, with very low rates of condom use. 4 Central Africa, on the other hand, is experiencing a more serious epidemic, as HIV prevalence exceeds 5 per cent in Cameroon, Central African Republic and Gabon. HIV transmission in Central Africa is mainly through commercial sex work and young women age are over two-and-a-half times more likely to have HIV than young men of the same age. 5 Evidence suggests that high rates of male circumcision in most countries of West Africa may have helped contain the spread of HIV and other STIs. 6 Key challenges Young people in West and Central Africa are growing up in countries that have some of the lowest social and human development indicators. They are among the world s poorest young people and have extremely high youth unemployment rates. Manchester United in Sierra Leone In 2008, UNICEF funded a multimedia communications campaign promoting HIV prevention amongst young people in Sierra Leone. Manchester United stars took part in the campaign, which ran nationwide across TV, radio and billboards in each of the country s 13 districts. Since 2002, the country has seen a 75 per cent increase in new HIV infections. Around 935,000 people (1.7 per cent) have HIV in Sierra Leone and as few as 17 per cent of young people understand how to protect themselves against the virus. The campaign aimed to deliver HIV prevention messages to the 3 million young people in Sierra Leone, utilising the huge popularity of football in the country. The advertising messages in the campaign concentrated on issues of stigma, encouraging safe sexual practice, and getting tested. Messages were developed and tested at grassroots level by young people in Sierra Leone UNICEF commissioned an independent survey to evaluate the campaign s impact on young people s knowledge and perception of HIV and AIDS. The results illustrate the campaign s impact on young people: Before the campaign, 70 per cent of respondents believed HIV and AIDS existed. This increased to 94 per cent post-campaign. Ryan Giggs, Manchester United player, featuring in the media campaign promoting HIV prevention in Sierra Leone. Before the campaign, 67 per cent of respondents agreed or strongly agreed that HIV and AIDS is a major concern for their community. This also increased to 94 per cent after the campaign. Before the campaign, 44 per cent of respondents said that they used a condom during their last sexual encounter. This increased to 62 per cent after the campaign. 12

15 ICA The political situation in the region is often unstable, with many countries currently in conflict or post-conflict situations, resulting in humanitarian crises and millions of displaced people. 7 One third of the population in West and Central Africa lives in a conflict zone, and gender-based violence, including rape of women and girls, is a grave problem that causes physical and psychological damage as well as increasing the possibility of HIV infection. 8 HIV prevention work in West and Central Africa continues to be severely underfunded and discussions on sexual issues remain controversial and taboo. Also, condom use is low in the region: fewer than 50 per cent of young people age use a condom in sexual relations with a non-regular partner. 9 A review of population-based surveys in West Africa showed that young men knew where to obtain condoms much more often than young women. 10 The boundaries between commercial and non-commercial sex are often blurred. Young women who exchange sex for gifts and/or money without regarding this as selling sex are unlikely to have many sexual partners, but these partners may be older and have other concurrent relationships. These types of partnerships require further investigation and focus as part of preventive education among young people. 11 Ten countries in the region have compulsory life skillsbased education as part of their formal national curricula. 12 However, this region has the lowest primary school attendance ratio in the world and the lowest attendance ratio at secondary level after Eastern and Southern Africa (see graph below). 13 Therefore, efforts to reach adolescents and young people out of school must be intensified. UNICEF in action In 2007, UNICEF worked closely with the Ministries of Education, youth networks and NGOs to involve young people in the development of appropriate educational materials, in the establishment of anti-aids youth clubs and in the training of peer educators. UNICEF is also advising national governments on how best to include responses for young people outside the school setting in National Strategic Plans, while also leveraging funds to implement the programmes. UNICEF supports programmes to reduce gender-based violence in conflict situations. For example, many fragile and post-conflict states have developed Emergency Preparedness and Response Plans and UNICEF works to ensure these plans include HIV prevention kits to reduce risk of transmission when such violent acts have been committed. 14 UNICEF has also actively supported communities to carry out risk mapping, to determine when and where adolescents and young people are at risk and how to form adequate interventions. The Youth Risk Mapping technique has been adopted by UNICEF s West and Central Africa Regional Office as a model for expansion throughout the region. In 2007, UNICEF worked with 16 countries in the region to implement programmes that specifically address HIVrelated risk factors for highly vulnerable adolescents. 15 Five countries 16 have now formalised national strategies to work with young adolescents on prevention issues and another five 17 have begun work to establish youth centres based on risk mapping in pilot communities. Children in West and Central Africa are least likely to attend primary school 100 Data not available for secondary schools Primary and secondary school attendance ratio by region, Primary school attendance 20 Secondary school attendance 0 Source: UNICEF, The State of the World s Children 2009, UNICEF, New York, Eastern & Southern Africa West & Central Africa Middle East & North Africa South Asia East Asia & Pacific Latin America & Caribbean CEE / CIS 13

16 MIDDLE EAST AND NOR Traditional and conservative societies in many of the countries in this region make open and frank discussion about sex and HIV controversial and taboo. HIV information is limited for this region but the available data indicates that in 2007, there were 98,000 young people age with HIV in the Middle East and North Africa. 1 With the exception of Sudan, the epidemics in this region are comparatively small in size. 2 However, there has been a continuous increase in the number of cases reported over the last five years, highlighting the urgent need to develop and increase the response to the epidemic in the region. The region has huge variations in HIV prevalence between specific populations, geographic areas and localities. While Djibouti and Sudan have generalised epidemics, with national adult HIV prevalence of 3.1 per cent and 1.4 per cent respectively, other countries in the region are reported as having low prevalence. 3 Surveillance systems are still largely inadequate and substantial HIV outbreaks among groups most vulnerable to HIV may have been overlooked. Various combinations of risk factors are associated with the epidemic in this region; chief among them are transactional sex and the use of contaminated drug injecting equipment. Key challenges Lack of adequate data is a major constraint in the region and much more focus is needed to generate data on the impact of HIV among young people, including more detailed information on prevalence, risk factors and behaviours. Wider socio-economic factors are also critical to determine vulnerability to HIV infection in the Middle East and North Africa. Extensive migration and conflict situations are factors particularly relevant to North Africa. In this context, young people are facing high rates of unemployment, delayed marital age, and changing lifestyles, as well as having a limited perception of their risk of HIV infection. Some governments have been resistant to the introduction of life skills-based education because they fear it might increase sexual activity. Many of the countries in this region have traditional, conservative societies where discussion of sexual activity is controversial and even taboo. UNICEF in action UNICEF and its partners have developed a range of innovative programmes to reach young people in the Middle East and North Africa, while at the same time safeguarding their safety and confidentiality, and respecting the cultures in which they live. For example, a confidential telephone hotline was established in Egypt, while street theatre and an extensive network of peer educators are having success in Tunisia. In Bahrain, technical support was provided to organise national youth-to-youth HIV training. First for Sudan As part of the first comprehensive communication campaign on behaviour change in northern Sudan, UNICEF Sudan ran a nationwide poster campaign. The poster on the right promotes confidential and free voluntary counselling and testing services, while the poster on the left delivers an anti-stigma message, informing people that You can stop HIV and AIDS and You can live and work productively with HIV. 14

17 TH AFRICA With the cooperation of the Sudan National AIDS Programme and the Federal Ministry of Information, UNICEF launched the first comprehensive communication campaign on behaviour change in northern Sudan. This campaign combined social mobilisation at the community level and coverage of HIV-related topics on television. UNICEF has also helped develop HIV life-skills curricula for primary and secondary education, voluntary confidential counselling and testing services, and the signing of an agreement with the Federal Ministry of Information and Communication for free primetime broadcast of HIV messages. In addition, more than 310,000 out-of-school young people were reached with information on skills to reduce their vulnerability through peer education and awareness-raising activities. Young peer educators and community workers have been reaching out to young people in their communities and in Internally Displaced Persons camps. 4 In Southern Sudan, more than 650 peer educators were trained in life skills participatory teaching to provide HIV prevention education to nearly 62,000 of their out-of-school peers in six states. Further, 18 voluntary and confidential counselling and testing centres provided access to free HIV counselling and testing for over 1 million people in eight of the 10 states of Southern Sudan. 5 Following two years of investment, Iran has seen a great expansion in adolescent-friendly service centres. Peer outreach education is being encouraged by local authorities and supported by communities. These services are now available in nine cities and 18 high risk areas. 6 In Tunisia, 2007 saw the successful culmination of years of continuous collaboration with the Ministry of Health, when a new law was passed authorising free voluntary counselling and testing, and initiating voluntary counselling and testing centres. 7 Village of hope Hope Village Society was created in the late 1980s to provide shelter and support to orphaned children from Cairo s poorer neighbourhoods. The Society soon realised that the local street children also needed a safe place to go where they could receive care and support, so they opened a day care centre. Today, there are 14 Hope Village day care centres. The children who attend the day care centres are particularly vulnerable to HIV because of the dangers they face such as sexual assaults, drugs, violence and prostitution. Girls are usually more at risk because they are sometimes abused by older boys, the police and others. With help from UNICEF and other sponsors, the Hope Village Society undertakes a wide range of activities from providing boys and girls with care and shelter to offering them psychological support, training and behavioural skills to help them reintegrate into society. HIV awareness has become an integral part of the work carried out by Hope Village, and UNICEF (in collaboration with UNAIDS) provides training on HIV and AIDS for the social workers at Hope Village. Children play at one of the Hope Village sites in Cairo, Egypt. UNAIDS/P.Virot 15

18 LATIN AMERICA AND TH High rates of income and gender inequality, migration, homophobia and a high degree of HIV-related stigma are apparent throughout the region. It is estimated that in 2007 there were 1.9 million people with HIV in Latin America and the Caribbean 1 and 160,000 new infections. 2 The region has approximately 400,000 young people with HIV. 3 Although the countries of this region share a number of similarities, the epidemics are heterogeneous. In Latin America, overall levels of HIV infection have changed little in the past decade. Several countries have stabilised at less than 1 per cent, although some of the smaller countries such as Belize, Guyana and Suriname have HIV prevalence ranging from 2.1 to 2.5 per cent. 4 In Latin America, HIV transmission occurs primarily among men who have sex with men, sex workers and (to a lesser extent) injecting drug users. At around 1.1 per cent, the Caribbean has the world s second-highest regional prevalence of HIV (after sub- Saharan Africa). The Bahamas has a HIV prevalence of 3 per cent and Haiti 2.2 per cent. At the other end of the scale, Cuba has one of the lowest at 0.1 per cent. The main mode of HIV transmission in the Caribbean is unprotected heterosexual sex, with commercial sex and sexual exploitation playing a significant role in many countries. 5 In the Caribbean, half of all people over the age of 15 with HIV are women, and in a few countries HIV prevalence among young women age is about two to three times higher than among men of the same age. 6 Sex between men, although generally denied by society, is also a significant factor in several national epidemics. 7 Key challenges Overall, HIV prevention efforts in the region have been small scale, slow, and largely dependent upon non-governmental organisations and international programmes. National responses have not sufficiently targeted groups engaging in high-risk behaviours, and there is a substantial lack of information on the magnitude and trends of the epidemic, particularly in the Caribbean. Extreme poverty, migration, homophobia and gender inequalities and a high degree of HIV-related stigma are apparent throughout the region and make young people particularly vulnerable to HIV. In a survey carried out in the Caribbean, half of all adolescents with sexual experience reported that their first sexual intercourse was forced. 8 A survey conducted in the eastern Caribbean showed that over two-thirds of respondents knew the main transmission routes for HIV, and knew that sharing a MTV and Xpress Now in its fourth year, Xpress, an hour-long programme for the Latin America and Caribbean audience, gives the microphone back to young people and experts to discuss core issues for youth and the wider society, such as drugs, violence, men who have sex with men, HIV and masculinity, and safe sex. The initiative aims at informing and educating a young audience about HIV prevention in an entertaining way. MTV Staying Alive In the documentaries, young people are given the opportunity to talk openly and honestly about core issues that affect them, including poverty, violence and social exclusion. Xpress forms part of Staying Alive, MTV s global multi-media HIV and AIDS prevention campaign, and is a co-production between Staying Alive, MTV Brazil, MTV Latin America, the MTV Caribbean channel Tempo and UNICEF Latin America and the Caribbean. It is available in English, Spanish and Portuguese, and free to all broadcasters and content distributors worldwide. We can t get effective HIV-prevention messages out to young people if we re not talking about poverty, about violence, about gender roles, about issues that are at the core of young people s sexuality and sexual behaviours, said Mark Connolly, UNICEF Regional HIV and AIDS Adviser. Adan Tejeda from the Red Cross in Dominican Republic talks on the UNICEF/MTV Xpress programme about the slums where many Haitian immigrants live and which are often neglected by the Dominican Government. In 2008, the documentary won a Silver Award in the education category at the World Media Festival. It featured celebrities such as dancehall sensation Ce cile, reggae star Tanya Stephens, and acclaimed music video director Ras Kassa. 16

19 E CARIBBEAN meal with someone with HIV carried no risk of infection. Yet fewer than one in five said they were willing to buy food from a shopkeeper with HIV. 9 Condom use in the region is low, resulting in large numbers of young people continuing to acquire HIV and extremely high rates of adolescent pregnancy (Latin America and the Caribbean has the second highest adolescent birth rate in the world). 10 A study in Trinidad and Tobago, for instance, found that fewer than one in five sexually active young men and women used a condom consistently. 11 In a study among sexually active young people in Peru, half the young men and over two thirds of young women reported never having used a condom. 12 Latin America and the Caribbean has some of the highest rates of inequality in the world. Currently, there are 104 million young people living in Latin America and the Caribbean 13 ; the largest cohort of young people in the region s history. Twenty-two million young people in the region are unemployed and out of school 14, yet only 4 per cent of out-of-school young people in the region have access to prevention services. 15 UNICEF in action In 2008, UNICEF co-sponsored the first meeting of Health and Education Ministers to stop HIV in Latin America and the Caribbean. At this meeting, a groundbreaking declaration was signed, recognising that respect for individual and cultural diversity throughout the region is crucial for effective prevention efforts and the reduction and elimination of stigma. Latin America and the Caribbean is home to hundreds of thousands of children that live and work on the street, many of whom become victims of sexual exploitation, and are especially vulnerable to HIV. UNICEF funds HIV-prevention activities among community-based organisations and programmes such as: street outreach; clinic-based education; counselling, testing, and referral programmes; programmes that address the specific needs of runaway, incarcerated, migrant, homeless, and other young people in high-risk situations. For example, in Salvador Bahia and Recife, Brazil, UNICEF supports the Brazil Active programme that, through 10 mobile centres and five drop-in centres, reaches thousands of children with information about HIV and also provides services to address the factors that make young people vulnerable to infection. The large number of early pregnancies in the region highlights the urgent need to provide adolescents and young people with sexual and reproductive health information and care. UNICEF works to strengthen the provision of youth-friendly services and health promotion activities, ensuring these are accessible to young people who are especially vulnerable. In 2007 the UNICEF-sponsored Bashy Bus, a mobile HIV prevention clinic, provided services to 15,000 young people. In the same year, Jamaica increased coverage of services for young people in vulnerable situations, through Youth Information Centres which reached 25,000 adolescents. 16 UNICEF also supports a number of media programmes, including soap operas, talk shows and public service announcements in the region to raise awareness and reduce the stigma of HIV. Get on board the Bashy Bus The demand for the Bashy Bus is huge. They spend long, long days, 13, 14, 20 hour days on site because we are getting our buses in town and everyone wants to find out. said Mark Connolly, UNICEF Regional HIV and AIDS Adviser. As with most of the countries in Latin America and the Caribbean, young people in Jamaica face tough issues like the social pressure on men to have many sexual partners and the pressure on children to have sex at a young age. Bashy is the Jamaican term for party and the Bashy Bus is transforming the future of Jamaican young people through music, theatre, dance and discussion about HIV and AIDS. As UNICEF Representative in Jamaica Bertrand Bainvel says, It is extremely difficult to implement prevention activities. We know that we have to regularly change the way we are reaching them because young people get bored easily. By travelling around the country and connecting directly with young people, the Bashy Bus crew inform young people of a full range of vital health services starting with HIV testing. Andre Lennon, age 20, is a youth leader working on the Bashy Bus and helping young people learn the truth about HIV and AIDS. Andre grew up in a violent neighbourhood, but he took a U-turn in life by joining in the Bashy Bus. Today, Andre encourages young The Bashy Bus is a successful and innovative UNICEF-supported way of delivering HIV prevention messages in Jamaica. people to do what he did: seek information and take an HIV test. I was vulnerable and could have had HIV... I will never ever engage in unprotected sex again. The Bashy Bus is just one example of the successful youth-driven initiatives that UNICEF and its partners have developed in the region. UNICEF 2007/Hannah Jones 17

20 SOUTH ASIA In South Asia, less than 10 per cent of HIV-prevention resources reach adolescents most at risk of acquiring HIV. All of the countries in South Asia have a low HIV prevalence with no country exceeding 0.5 per cent. 1 However, low national averages mask serious epidemics concentrated in some geographical areas and among groups engaging in particular high-risk behaviours. Given the large populations of some countries in the region, even low prevalence rates mean very large numbers of people with HIV. For instance, India has an overall HIV prevalence rate of just 0.3 per cent (masking wide regional disparities) but the world s third largest number of people with HIV (after South Africa and Nigeria). 2 Although there is considerable variation in the nature and severity of the epidemics across countries in South Asia, they share important characteristics. Their most profound similarity is that they are driven by three key behaviours that are responsible for an estimated 75 per cent of all infections in the region. 3 These behaviours are: unprotected sex in the context of sex work; unsafe injecting drug use; and unprotected sex between men. South Asia s population is characterised by a young age structure. More than one third of Nepal s population is between 10 and 24 years old, over 45 per cent of Afghanistan s population is under the age of 14, and nearly 60 per cent of Maldivians are under the age of In 2007 there were 690,000 young people age with HIV in South Asia. 5 Around 5 to 15 per cent of young people are considered especially vulnerable. These include: street children; those who have been sexually abused; young people in prison; children of parents with HIV; sex workers or injecting drug users; orphans; and migrants. 6 A further 1 to 5 per cent are most-at-risk adolescents, who practise high-risk HIV transmission behaviours such as unprotected sex in the context of sex work, unsafe injecting drug use and unprotected sex between men. 7 Adolescents engaging in one or more of these risk behaviours account for up to 95 per cent of all HIV infections in their age group. 8 Early marriage of girls (often to older men), migration and social mobility, trafficking for sexual purposes, neglect or abuse within households, and sex tourism are some of the other factors that increase adolescents vulnerability to HIV infection. 9 In a number of countries, significant numbers of sex workers are under the age of 20 (see table opposite). 10 In some instances, delayed marriage has contributed to a rise in pre-marital sex, often practised unsafely and with different partners. 11 Young wives of migrant workers are also at greater risk of HIV than other women because the incidence of HIV is high among returning migrant workers. In Nepal, for instance, HIV prevalence among seasonal migrant labourers is 1.9 per cent. 12 Take the Red Ribbon Express On World AIDS Day (1 December) 2007, the Red Ribbon Express train a groundbreaking HIV prevention campaign departed from Safdarjung Railway Station, New Delhi, India. In a year-long journey, the train stopped at about 180 stations and reached more than 50,000 villages with critical information on HIV prevention. At each station stop, a network of young communicators remained on the train to provide information and services, while 60 performance artists left on a fleet of bicycles to visit dozens of villages. The performers staged plays and skits about stopping HIV and fighting stigma and discrimination. Another group of young campaigners travelling by bus covered an even larger area than the cyclists at each stop. The train is a mobile education and exhibition centre using technologies such as interactive touch screens and 3D models. It has its own auditorium to host education sessions for anganwadi (childcare centre) workers, self-help groups and non-governmental organisations for youth and women. A separate coach holds six cabins for counselling and medical services. UNICEF, a key partner of the Indian Government and the Rajiv Gandhi Foundation, contributed over $1.2 million to the Red Ribbon Express project. The train proved a vital component of UNICEF s HIV prevention work in India. Young performers in front of the Red Ribbon Express at Safdarjang Station, New Delhi. At each station stop, they cycle to nearby villages, where they stage plays on HIV prevention. There really is no better expression of the Unite campaign in India than the Red Ribbon Express, Dr Gianni Murzi, UNICEF Representative in India, said at the launch event. He noted that the train s journey through 22 states would spread the message of health and hope for all people affected by HIV and AIDS and at risk of infection. UNICEF India/Sandeep Biswas 18

21 Key challenges Most HIV prevention programmes aimed at young people in South Asia do not focus explicitly on the three key behaviours that put them at greater risk of acquiring HIV. Programmes have instead tended to focus on heterosexual sexual transmission and on adolescent reproductive health. As a result, there has been only limited impact on preventing new infections among young people. In fact, adolescents at greatest risk of acquiring HIV receive less than 10 per cent of prevention resources. 13 Across South Asia, laws prohibiting or criminalising high-risk behaviours act as constraints to the use of services by young people and contribute to high levels of stigma and discrimination. Young people in vulnerable situations have very limited access to information and use of health services. The availability of strategic information for monitoring HIV is still relatively weak across the region, and data on the impact of HIV prevention programmes targeted at adolescents is sparse. However, there is sufficient evidence to outline two dominant trends. The first is that there has been an increase in female sex workers under the age of The second is that there is a reduction in the age of initiation for injecting drug users. 15 Both trends are a threat to the healthy development of adolescents and reveal the widespread existence of a subculture of abuse and exploitation of, and risk-taking among, adolescents. UNICEF in action South Asian countries are still at relatively early stages of the epidemic curve, so there is an opportunity to reverse The availability of strategic information for monitoring HIV is still relatively weak across the region. High rates of young women sex workers in Asia the spread of HIV if carefully focused and expanded prevention work starts now. UNICEF has been at the forefront of providing strategic and technical advice to governments about the need for policy to be consistent with epidemiological evidence in the region, which suggests three broad target groups of young people: those engaging in high-risk behaviours; those likely to start engaging in these behaviours (such as street children); and those at lowest risk and vulnerability to HIV. Several countries (India, Pakistan, Maldives and Nepal) have now revised their national HIV strategies so that priority has been given to expanding a targeted HIV response for especially vulnerable and most-at-risk young people. In 2007, UNICEF supported Pakistan s Child Protection and Empowerment of Adolescents programme (CPEA), which focused on commercial sexual exploitation, sexual abuse, juvenile justice, corporal punishment, adolescent empowerment, HIV and AIDS, and child participation. This programme included life skills-based education aimed at vulnerable and most-at-risk children and young people. The focus of the epidemic in South Asia means that, within a broader context of HIV awareness, prevention is essentially a matter of child protection creating an environment in which the most vulnerable young people are protected from exploitation and drug use, empowered with the knowledge and capacity to protect themselves by avoiding or managing high-risk behaviours, and able to access help and support when they need it. Percentage of female sex workers under the ages of 20 and 25 in various Asian countries. Under 25 years old Under 20 years old SOUTH ASIA Source: UNICEF, UNFPA and UNESCO, Responding to the HIV prevention needs of adolescents and young people in Asia: Towards (cost-)effective policies and programmes, 2007, p Viet Nam Indonesia, national Nepal India, national India, Orissa Bangladesh Indonesia, Riau Cambodia Sichuan, China Laos 19

22 EAST ASIA AND PACIFIC Injecting drug use and sex work are major risk factors in the epidemics of East Asia and the Pacific. Yet a chronic lack of data on which young people are most-at-risk hampers effective prevention efforts. In the East Asia and Pacific region, there are 2.4 million people with HIV 1, 580,000 of whom are young people age Cambodia, Myanmar (Burma) and Thailand all show declines in HIV prevalence although Thailand still has a prevalence of 1.4 per cent. 3 But HIV continues to spread in other countries such as China, Indonesia (one of the fastest growing epidemics in Asia), and Viet Nam, where the estimated number of people with HIV more than doubled between 2000 and Injecting drug use and sex work are major risk factors in the epidemics of East Asia and Pacific, and in many countries there is an overlap of these behaviours. For example, around half the people with HIV in China in 2006 are believed to have been infected through the use of contaminated needles. An increasing number of women are injecting drugs in China, and substantial proportions of them (about 56 per cent in some cities) also sell sex. 5 As in most other regions in the world, unprotected sex between men is a potentially significant but under-researched factor in the HIV epidemics of East Asia and Pacific. 6 Where data is available, it shows that the majority of infections in East Asia and Pacific occur between the ages of Adolescents below the age of 18 appear not to be the key drivers of HIV in the region. 8 Women and girls who have been trafficked for sexual purposes face especially high risks of HIV infection. 9 Social, political and economic trends must be closely monitored because they may change the course of the region s HIV epidemics. In recent years, East Asia s dazzling economic growth has lifted the fortunes of millions of people, but it has also led to developments that may fuel the spread of HIV. Key challenges Although all countries in East Asia and Pacific have National Strategic Plans, only a few have developed a comprehensive prevention strategy for adolescents most at risk. A major issue in ensuring inclusion of the most-at-risk adolescents in these plans has been the absence of age and gender-disaggregated data. Most National Strategic Plans in the East Asia and Pacific region prioritise prevention among the most-at-risk At the hub In 2008, the UNAIDS Regional Support Team for Asia-Pacific, WHO, UNICEF and the Asian Development Bank joined up to launch an internet data hub containing information on HIV and AIDS. Currently most data sets are maintained at a global level, but regional and country-level summaries are not readily accessible. The Data Hub contains 133 internationally agreed, standardised indicators and over 600 sub-indicators on HIV and AIDS for 24 countries as well as the Hong Kong Special Administrative Region of China. Good quality and up-to-date data are critical for national and subnational planning and for monitoring progress, especially in the East Asia and Pacific region, where the HIV epidemic is largely concentrated among sub-populations. This pattern of transmission calls for better geographic and sub-population targeting, improved data collection disaggregated by age and sex, as well as continuous monitoring. The Data Hub project aims to generate an accessible, easy-to-use database containing data on HIV vulnerability, risk behaviours, infection and disease, the impact of the epidemic and responses to it for use by governments, the public, researchers, the UN system and donors. The Hub will enable UNICEF to influence national agendas on children and AIDS and help make policy and programme responses more effective through the use of timely, accessible and meaningful data. The Data Hub website, 20

23 population but inadequate analysis, by age, gender and risk factors makes it impossible to provide targeted interventions for boys and girls most at risk. For example, data is not collected to indicate whether out-of-school adolescents are at increased risk of HIV, so consequently out-of-school young people are not targeted for strategic intervention. 10 UNICEF in action UNICEF continues to support capacity building for HIV data analysis and reporting. In partnership with the UNAIDS Regional Support Team for Asia-Pacific, WHO and the Asian Development Bank, an internet data hub was set up in 2006 and launched in early The Hub provides an online data resource for 24 countries and, with a governing structure comprised of national scientists, epidemiologists and policymakers, will enable UNICEF to help reinforce practices of using data to drive policy, advocacy, strategic planning and programme responses. UNICEF continues to work with WHO at the regional level to increase training and access to HIV testing and counselling. At country level, UNICEF has supported the establishment of new counselling and testing sites in Cambodia and Papua New Guinea. 11 UNICEF continues to work with WHO at the regional level to increase training and access to HIV testing and counselling. In Mongolia, UNICEF s advocacy efforts led to the establishment of the National Voluntary Counselling and Testing Working Group and the approval of the Voluntary Counselling and Testing Action Plan for In addition, UNICEF facilitated the first national training of trainers on vulnerable counselling and testing. UNICEF also helped to develop a life skills-based education curriculum for non-formal education which has been approved by the Ministry of Education, Culture and Science. 12 In 2007, UNICEF and the Democratic People s Republic of Korea s (North Korea) Ministry of Education reached an agreement for expanding life skills-based learning to areas such as interpersonal relations and communication, paving the way for introducing messages related to HIV and AIDS prevention. 13 In Myanmar (Burma), an evaluation of UNICEF s life skills-based training and peer education for out-of-school young people led to the revision of training content and an increased focus on young people at higher risk of contracting HIV. A new partnership was forged with the Myanmar Antinarcotic Association to reach young people in drug-using communities. A total of 9,400 young people were trained as peer educators in 18 townships, bringing the total number of community peer educators to nearly 55, For many years, Maila (age 20) has been surviving as a sex worker on the streets of Quezon City, Philippines. She has been molested many times, and was once raped by a police officer, but was too afraid to report the incident. Today, Maila speaks with other adolescents about the dangers of HIV and other sexually transmitted diseases, and tries to help other out-of-school, at-risk girls find safer ways of earning a living. She dreams of finding a good job so that she can quit her dangerous occupation. 21

24 CENTRAL AND EASTERN COMMONWEALTH OF IND High rates of substance abuse, institutionalisation, human trafficking and unemployment make young people especially vulnerable to HIV. Central and Eastern Europe (CEE), including the Commonwealth of Independent States (CIS), are experiencing one of the steepest increases in the spread of HIV worldwide. The Russian Federation has the largest HIV epidemic in this region and it is continuing to grow, although at a slower rate than in Ukraine where annual new HIV diagnoses have more than doubled since Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, Tajikistan, and Uzbekistan all have rising numbers of annual new infections. 1 In 2007, there were 340,000 young people age with HIV in the region, 65 per cent of whom were young men. 2 Adolescents in the region who are especially vulnerable to HIV are those who live or work on the streets, are in juvenile detention or institutional care, or come from marginalised ethnic populations (such as Roma). Adolescents most at risk are those who inject drugs, those who engage in transactional sex, and men who have sex with men. Across the region, many young people have grown up experiencing violence, conflict and post-conflict situations. As a result, young people face poverty and unemployment levels that are significantly higher than among older age groups. CEE and the CIS has the second highest youth unemployment rate in the world, after the Middle East and North Africa region. 3 Economic transition has led many parents to emigrate in search of employment, resulting in large numbers of children being left at home alone, increasing Zhenia, age 19, sits on his bed at the Way Home shelter for children who live or work on the streets of Odessa, Ukraine. He is a drug user and has HIV, but does not have access to anti-retroviral (ARV) medicines. UNICEF/ /Pirozzi their vulnerability to substance abuse and other risk behaviours. Institutionalisation is also a real concern across the region and is having a severely detrimental impact on the life chances of children. According to recent reports, the number of children in residential care is increasing in 12 of the 20 countries in the region. 4 The number of adolescents living and/or working on the streets is also increasing, particularly in Russia and Ukraine. A recent survey of adolescents age 15 to 19 living and/or working on the streets of St Petersburg found that nearly 40 per cent had HIV..5 There are high rates of substance abuse among adolescents and young people in the region and especially high rates of drug injection influenced by drug trafficking. In fact, the region has the world s highest prevalence of injecting drug use. 6 Moreover, every country in the region is a country of origin, transit or destination for trafficking for sexual exploitation and around 15 per cent of females who are trafficked are estimated to be under the age of Key challenges The main challenge in HIV prevention work in the region is to ensure that effective measures are in place to mitigate the rate of HIV transmission and maintain low prevalence of HIV in most countries. Equipping young people, in particular those at highest risk of HIV infection, with the information, education, services, protection and support required for reducing their risk-taking behaviours and vulnerability to HIV is critical. High levels of intolerance and discrimination toward marginalised groups are strong throughout the region. Fear of prosecution or persecution for drug use, sex work or homosexuality deters many young people from accessing services. Many adolescents who engage in these risk behaviours are excluded from health programmes because of a number of obstacles. For instance, in many countries, only those age 18 and over are legally allowed to access health services without a parent s knowledge or permission. In some Central Asian countries, drug treatment programmes are required to report clients to the police. Also, if adolescents are found to have a STI, the police will attempt to trace their sexual contacts, and they may face criminal charges if they are discovered to have been practising male to male sex. Many nations of the former Soviet Union have strong reporting requirements and health workers may be prosecuted if they fail to comply. Therefore, in many cases, health workers choose not to treat adolescents. 8 22

25 EUROPE AND THE EPENDENT STATES The region suffers from a chronic lack of data, particularly data on the behaviour of young people and data disaggregated by gender or age. Many adolescents engage in multiple risk behaviours: for example, adolescents may buy or sell sex in exchange for drugs. This interplay between injecting drug use and unprotected sex, much of which is transactional, is a serious issue in the region, yet prevention strategies often focus on just one risk behaviour and rarely address combinations of risk-taking. UNICEF in action Since 2006, UNICEF in partnership with UNAIDS, Irish Aid and others has been working with the London School of Hygiene and Tropical Medicine to look at adolescents risk behaviour and awareness and use of services in seven countries in the region. 9 By building the evidence base among adolescents most at risk as well as vulnerable groups including street children, Roma and institutionalised youth UNICEF aims to: strengthen national capacity in data collection; increase stakeholder commitment to issues that affect most-atrisk adolescents; reform legislation that inhibits access to services among adolescents under the age of 18; and develop communication strategies for behaviour change that can be integrated into National AIDS Strategies. UNICEF is putting emphasis in these countries on promoting the expansion of health and harm reduction services for adolescents age because they make up a significant portion of those practising drug use and sexual risk behaviours for the first time. UNICEF s direct technical assistance is ensuring that studies among adolescents and young people most at risk of HIV are included in national baseline data and can be used to monitor progress in the implementation of Global Fund grants. Albania, Bosnia and Herzegovina and Serbia have been able to leverage major Global Fund funding as a result of UNICEF-supported data collection efforts. 10 UNICEF is also supporting education initiatives with a focus on the development of standards, teacher training and advocacy for the inclusion of life skills-based education into national curricula in 15 countries of the region. In 2007, UNICEF provided technical assistance in 15 countries toward the development of youth-friendly service policies and standards, advocacy for national ownership of youth-friendly health services, and building the capacity of health service providers. UNICEF also promoted the opening of new youth-friendly health centres and supported the participation of children and young people in dialogue over policy affecting their health and well-being in at least 10 countries. 11 The transmission of HIV among vulnerable young people involved in multiple risk behaviours requires a new culture of engagement with marginalised youth, through which they can access help and support to reduce the most harmful effects of their behaviours and ultimately to change them. This means health services they can access without fear, needle exchanges for injecting drug users, increasing condom use by sex workers and men who have sex with men, tackling discrimination, and new skills and opportunities to offer young people a stake in society. If we do not address the needs of today s vulnerable and marginalised young people, the epidemics in CEE and the CIS could become generalised. Young people and injecting drug use in CEE and the CIS Percentage of injecting drug users under the age of 25 Age of injecting initiation, years Parental consent required for drug treatment? Georgia 16.8% of injecting drug users in contact with harm reduction services 20.1 Required in practice for minors Romania 49.3% of injecting drug users in contact with harm reduction services. (An estimated 80% of all injecting drug users are under the age of 29.) Initiation age is falling, starting as early as Yes. Parents are also required to be present during medical evaluation prior to admission. Russia 12% of male Muscovites age have injected drugs Many begin injecting between 11 and 17. Yes, for clients 18 and under. Clients age must also give their own consent. Serbia Yes Ukraine 25 58% of injecting drug users in Ukraine may be under % of 4,143 injecting drug users tested in 2007 were age Yes Source: Eurasian Harm Reduction Network (EHRN), Tables 1, 2 and 9, Young people & injecting drug use in selected countries of Central and Eastern Europe, Vilnius,

26 UNITED KINGDOM Today, there is a record number of 77,000 people with HIV in the UK with more than a quarter unaware of their infection. 1 There were 7,734 new HIV diagnoses reported in 2007, nearly double the number reported for 2000 (3,875) and by far the highest number of new infections in Western Europe. 2 In the UK, HIV is concentrated among two key groups; men who have sex with men and migrant populations from sub- Saharan Africa. In 2007, young people (age 16 24) accounted for around 10 per cent of all new HIV diagnoses in the UK. Young men who have sex with men remain the group of young people most at risk of acquiring HIV. More widely, young people are the group most at risk of other STIs. Young people make up one in eight of the UK population, but account for around half of all the 400,000 infections diagnosed in sexual health clinics across the UK in Furthermore, the number of reported infections continues to rise. We urgently need to address this disproportionate burden on young people. Peter Boriello, Director of the Health Protection Agency s Centre for Infections, has said that we cannot rely on prompt diagnosis and treatment alone a shift in behaviour is the only way that we will bring down this continued increase in infections. The UK needs to do more to encourage young people to practise safer sex if we are to see a reduction in STIs. UNICEF UK Youth Champions are actively involved in HIV prevention campaigns. In 2007, they visited HIV-prevention programmes in Jamaica and were inspired to adopt some of the methods for their HIV prevention work in the UK. The Champions introduced the Just Say Yes to talking about and taking action on HIV and AIDS activity pack for Brownies and younger Guides. Children s right to health and health services Having ratified the UN Convention on the Rights of the Child, the UK Government is obliged to strive to ensure that children 3 have the highest attainable standard of health and the right to access health services. For young people, information and sexual health services are essential to ensure that they can maintain the highest attainable standard of health. But research from the UK Youth Parliament shows that 40 per cent of young people between the ages of 11 and 18 thought that their Sex and Relationships Education (SRE) was either poor or very poor, and another third thought it was average. 4 In 2008, in response to pressure from young people, teachers and civil society, including UNICEF UK, the Government announced that Personal, Health and Social Education, including SRE, would become a statutory part of the curriculum for schools in England. In order for this new policy to be implemented effectively, it is essential that teachers receive training to deliver this critical subject appropriately. Recent research shows that some young people, especially young women, find it hard to access sexual health services. 5 They report that visiting a sexual health clinic can be an intimidating and awkward experience. This is exacerbated by the difficulties experienced in making appointments. The long waiting times at walk-in centres mean many people give up and leave. There is an urgent need for more sexual health services designed and commissioned with, and directly addressing the needs of, young people. UNICEF UK/2008/Jessica Wright 24

27 CONCLUSION Ainy reversal in the spread of HIV will depend on the behaviour of young people the adults of tomorrow. Tragically, most young people do not have the information, skills, access to services, or support they need to avoid or mitigate risky behaviours. The tremendous variation in the personalities and circumstances of young people drive their choices. HIV prevention responses must therefore be tailored to meet the wide-ranging needs of such a diverse group. Prevention policies and programmes designed for adolescents and young people engaging in high-risk behaviours are a critical priority where behaviours such as injecting drug use, men having sex with men, intergenerational sex and sex work are driving HIV transmission. This requires greater openness in dealing with these sensitive issues and reaching out to, rather than stigmatising, those engaging in high-risk behaviours. In generalised epidemics where children are in school, the education sector is a crucial route for reaching adolescents with the clear and accurate gendersensitive information and skills that are a necessary part of preventing the spread of HIV. A supportive policy environment will facilitate the work of the education sector in adapting and updating life skills-based programmes in schools, especially where the content of these programmes includes potentially sensitive issues. Life skills-based programmes are a necessary part of national prevention strategies, but not a sufficient one they need to be combined with a number of other approaches if they are to lead to behaviour change among young people, particularly those who are out of school and/or marginalised. sustainable prevention programmes, we will undermine all the gains made in the treatment of HIV. Ultimately, governments and partners must become much better at knowing their epidemic and knowing their young people. Improved knowledge about which young people are most at risk is vital for developing effective and lasting national prevention strategies, but this depends on the availability of high quality, disaggregated data. Only with this information can countries employ an appropriate combination of interventions suited to the local environment. If HIV prevention was implemented using a combination - based approach, it is estimated that more than half of the new infections between now and 2015 could be averted. That would mean 12 million fewer HIV infections occurring between now and 2015 (if incidence remained constant at today s levels). 2 It is hoped that by knowing young people better and how HIV affects them, and by understanding the implication of evidence and best practices for their care, the next generation of children will be able to live free from HIV. A girl listens to a presentation on HIV at the United Methodist Church in Kikolo, Angola. UNICEF supports life-skills training for adolescents in partnership with churches and youth councils. More resources need to be invested in campaigns that reflect the lives of young people and harness the outreach potential of sport as well as communication technologies such as mobile phones 1. The meaningful involvement of young people in the design, implementation and evaluation of such programmes is essential to their success. Even when young people have access to the right information and services, social and cultural norms often preclude them from adopting safe behaviours. Currently, a concerted and sustained effort to address the underlying social drivers of HIV may be the only way to change the course of the epidemic and its effects. Leadership, at the highest level, is urgently needed for this to be effective. For young people, the long-term goal should not just be about behaviour change it should be about motivating and enabling informed, safer behaviour from the start. For this to happen, young people need to grow up in a safe and supportive environment. Our experiences have shown us that prevention work is a long-term and continuous process and has no quick fix. But if we do not focus attention on successful and UNICEF/NYHQ /Nesbitt 25

28 RECOMMENDATIONS 1. Combine prevention strategies A broad range of prevention strategies are available and need to be used in combination to meet the specific needs of adolescents and young people at risk. To be effective, HIV prevention programmes for adolescents and young people must combine information and skills, access to health and other services, as well as a safe and supportive environment. 2. Prioritise high-quality data Quantitative and qualitative data is a prerequisite to identifying those young people who are most at risk, understanding trends, and evaluating prevention programmes. Data that is disaggregated by factors such as age, sex, marital status, wealth quintile and geographical location (urban or rural) can drive better programming. Improved knowledge about which young people are most at risk is vital for developing effective and lasting national prevention strategies. 3. Make prevention programmes more relevant to young people Prevention approaches must respond to the evidence and understanding of the epidemic in different contexts and be tailored to the specific needs of adolescents and young people. National strategic plans with a focus on HIV prevention should include clear targets and mechanisms for monitoring progress. In addition, evaluation is needed to assess the impact of HIV prevention efforts through the mass media, sports and celebrity involvement. 4. Strengthen links between treatment and prevention HIV prevention, diagnosis, treatment and care should be integrated within existing health infrastructures, which must be youth-friendly. Young people need to receive appropriate prevention counselling as part of voluntary testing and prevention of mother-to-child transmission services. Those with HIV need information about how to live a positive and healthy lifestyle, how they can influence the progression of the disease, what their treatment and care options are, and how to prevent transmission to others. 5. Nurture a prevention movement This requires not only community mobilisation and ownership, but also political commitment at the highest level. Prevention is for life and must be re-enforced at every stage it should not stop when adolescents become adults. An active civil society is needed to mobilise public support and hold national governments to account. Adolescence is a time of experimentation and behaviours that increase the risk of HIV can often begin during this life phase. A clear, comprehensive strategy is crucial to help guide adolescents and young people to lead safer and healthier lives. A boy films a girl leaning through a window in Goma, North Kivu, D.R. Congo. He is a peer educator and is interviewing people about their knowledge of HIV and AIDS. The media project is part of a UNICEF-supported campaign to promote HIV awareness and prevention in D.R. Congo. UNICEF/ /Pirozzi 26